Medicaid Consult for Data Capture

Job description

·  Job Description:

The Insurance/Healthcare job family contains positions associated with providing consultancy utilizing knowledge and expertise on insurance and healthcare. Develops and implements general insurance and health policies in accordance with state and federal laws. Provides expertise to investigate and adjudicate claim characteristics that do not match policy provisions. Responds to provider appeals and meets with providers to resolve problems/issues. Provides directions for utilization review. Approves any remedial or recoupment actions associated with escalated claims. Advises provider review councils, state officials and works with organized healthcare groups and associations on various medical issues related to insurance and healthcare programs

Responsibilities:

·  Participates and coordinates the identification, documentation, analysis and validation of advanced business processes, systems, and solution requirements.
·  Researches, evaluates, and designs components of complex solutions to problems.
·  Provides expertise to support requirements of cross- functional initiatives and projects, while contributing to the development and techniques used to meet the requirements of the business unit. Leads and contributes in process review and improvement initiatives.
·  Ensures customer satisfaction by handling unique and difficult situation/projects under minimal direction in a timely and quality manner.
·  Able to resolverecommend action on most issues.
·  Handle escalated issues from customers with minimal assistance.
·  Ability to design and implement training programs for internal and external customers.
·  Serve as liaison between customer and account staff with regard to training and education.
·  Manage multiple assignments with no supervision.

Education and Experience Required:

·  Bachelor's degree in insurance, healthcare or related field.
·  Must have current certification and licensing in area of expertise.
·  May hold advanced certification in work field.
·  Typically minimum of 8+ years of relevant experience with Bachelor's degree.
·  Typically, 8-10 years of working experience.
·  Must possess current certification, including necessary licenses, for the field of specialty (as required).

Knowledge and Skills:

·  Experience with expert knowledge of commercial and government insurance programs.
·  Expert level of understanding and application of healthcare related technologies.
·  Extensive knowledge and experience with project management, research and problem resolution techniques.
·  Subject matter expert regarding policies and procedures.
·  Ability to plan, develop and manage the scope of a complex projects/issue with minimal direction from leadership.
·  Excellent written, verbal, and presentation skills.
·  Demonstrated ability to develop and present a wide variety of materials and communications that will be used to effectively reach both internal and external customers, and build trusting relationships through collaborative work activities.
·  Ability to effectively train team members.
·  Proven ability to work effectively and lead a team.
·  Ability to teach others to research and resolve customer inquiries by identifying trends and utilizing available resources.
·  Self-motivated with excellent time management and organizational skills.
·  Ability to work and communicate with high level executives and government officials.
·  Must possess current certification, including necessary licenses, for the field of specialty (as required by the position).